**Current Treatment for Carpal Tunnel Syndrome**

**Current Treatment for Carpal Tunnel Syndrome**

DOI: 10.5772/intechopen.72946

Leonel Garcia Benavides, Sylvia Elena Totsuka Sutto, Leonel Garcia Valdes, Simon Q. Rodríguez Lara, Guillermo Ramos Gallardo, Ana Rosa Ambriz Plascencia and Miriam Méndez del Villar Leonel Garcia Valdes, Simon Q. Rodríguez Lara, Guillermo Ramos Gallardo, Ana Rosa Ambriz Plascencia and Miriam Méndez del Villar Additional information is available at the end of the chapter

Leonel Garcia Benavides, Sylvia Elena Totsuka Sutto,

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.72946

#### **Abstract**

The combination of surgical procedure (open or endoscopic techniques), rehabilitation and antioxidant therapy (Alpha lipoic acid, curcumin) is superior to monotherapies in the prognosis and recovery of patients with this pathology. The prescription of these medications by their mechanisms of action should be allocated prior to decompression surgery and should continue receiving medication during the rehabilitation time. Clinical and electrophysiological follow-ups are required to verify the improvement.

**Keywords:** carpal tunnel syndrome, median nerve entrapment, compression neuropathy

#### **1. Definition**

The American Academy of Orthopedic Surgeons (AAOS) defines the carpal tunnel syndrome (CTS) as the most common form of entrapment neuropathy of the median nerve, and the syndrome affects 3.8% of the general population [1], with an incidence in both genders of 376 per 100,000 US habitants [2] combined and with a prevalence that usually varies in relation to the risk factors of a specific population; a study among poultry processing employees reported an estimated prevalence of 42%. CTS is one of the most common clinical problems encountered by hand surgeons. Although this syndrome is widely recognized, its etiology remains largely unclear [3].

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons

## **2. Anatomy**

The median nerve (MN) derives from the brachial plexus as a terminal branch of the medial and lateral cord. The fibers from the lateral cord (C6–7) provide sensitivity to the thumb, the index and the middle finger, as well as the motor fibers of the proximal muscles innervated by the median nerve (palmar muscles, pronator teres muscle). The medial cord (C8-T1) supplies most of the motor fibers to the distal muscles of the forearm and the hand, as well as the sensitivity to the external part of the ring finger. The MN descends through the arm without creating any branches until it reaches the forearm, just beneath the head of the pronator teres muscle, where its most important branch originates, the anterior interosseous nerve of the forearm. This nerve supplies the flexor pollicis longus, flexor digitorum profundus and pronator quadratus. Multiple muscular branches arise from the MN during its path, which supply the pronator teres, flexor carpi radialis, palmaris longus and flexor digitorum superficialis muscles. Proximal to the wrist and the carpal tunnel (CT), the palmar branch of the median nerve emerges and innervates the skin of the thenar eminence [4] (**Figure 1**).

In the palm of the hand, the MN sends a motor branch to the lumbricals of the index and the middle finger as well as a recurrent branch to innervate the muscles of the thenar eminence (abductor pollicis brevis, flexor pollicis brevis and opponens pollicis). The proper palmar

> digital nerves are sensory fibers that supply the skin of the index and the middle fingers as well as the medial part of the ring finger and medial surface of the thumb [4] (**Figure 1**). There are multiple anatomical variants in the path and distribution of the MN, which could be present in up to 11% of the population. The most common variants are the presence of a medial residual artery, which is an embryological remnant that usually suffers a regression in the second trimester but could persist in 5% of the population, and it is also related to the presence of the CTS, and the anastomosis of Martin Gruber, which is a motor communication between the median and ulnar nerve at the forearm, which could have its origin from the union of the principal fibers of these nerves or in the anastomosis of the anterior interosseous nerve with

**Figure 2.** Anatomical elements involved in the procedure to open the transverse carpal ligament.

The carpal tunnel connects the anterior compartment of the forearm to the palm of the hand. It is delimited medially by the pisiform bone, laterally by the hamulus of the unciform bone, posteriorly by the scaphoid bone and the trapezoid bone and its roof by the transverse carpal

**2.** Medial: the space comprehended between the pisiform bone and the unciform bone, and it

Many structures pass through the carpal tunnel, such as eight flexor tendons of the fingers (four superficialis and four profundus) and the flexor pollicis longus, and usually the localization of the median nerve is superficial to the tendons and medial to the flexor pollicis longus [4] (**Figure 2**).

.

Current Treatment for Carpal Tunnel Syndrome http://dx.doi.org/10.5772/intechopen.72946 41

the ulnar nerve and it is present in 5–10% of the population [5].

**1.** Proximal: it includes the volar carpal ligament, originated in the forearm.

has approximately 20 mm of width and a transversal area of 1.6 cm<sup>2</sup>

**3.** Distal: it corresponds to the origin of the palmar aponeurosis.

ligament. It can be divided into three portions:

**Figure 1.** Median nerve pathway.

**Figure 2.** Anatomical elements involved in the procedure to open the transverse carpal ligament.

**2. Anatomy**

40 Essentials of Hand Surgery

**Figure 1.** Median nerve pathway.

The median nerve (MN) derives from the brachial plexus as a terminal branch of the medial and lateral cord. The fibers from the lateral cord (C6–7) provide sensitivity to the thumb, the index and the middle finger, as well as the motor fibers of the proximal muscles innervated by the median nerve (palmar muscles, pronator teres muscle). The medial cord (C8-T1) supplies most of the motor fibers to the distal muscles of the forearm and the hand, as well as the sensitivity to the external part of the ring finger. The MN descends through the arm without creating any branches until it reaches the forearm, just beneath the head of the pronator teres muscle, where its most important branch originates, the anterior interosseous nerve of the forearm. This nerve supplies the flexor pollicis longus, flexor digitorum profundus and pronator quadratus. Multiple muscular branches arise from the MN during its path, which supply the pronator teres, flexor carpi radialis, palmaris longus and flexor digitorum superficialis muscles. Proximal to the wrist and the carpal tunnel (CT), the palmar branch of the median

In the palm of the hand, the MN sends a motor branch to the lumbricals of the index and the middle finger as well as a recurrent branch to innervate the muscles of the thenar eminence (abductor pollicis brevis, flexor pollicis brevis and opponens pollicis). The proper palmar

nerve emerges and innervates the skin of the thenar eminence [4] (**Figure 1**).

digital nerves are sensory fibers that supply the skin of the index and the middle fingers as well as the medial part of the ring finger and medial surface of the thumb [4] (**Figure 1**). There are multiple anatomical variants in the path and distribution of the MN, which could be present in up to 11% of the population. The most common variants are the presence of a medial residual artery, which is an embryological remnant that usually suffers a regression in the second trimester but could persist in 5% of the population, and it is also related to the presence of the CTS, and the anastomosis of Martin Gruber, which is a motor communication between the median and ulnar nerve at the forearm, which could have its origin from the union of the principal fibers of these nerves or in the anastomosis of the anterior interosseous nerve with the ulnar nerve and it is present in 5–10% of the population [5].

The carpal tunnel connects the anterior compartment of the forearm to the palm of the hand. It is delimited medially by the pisiform bone, laterally by the hamulus of the unciform bone, posteriorly by the scaphoid bone and the trapezoid bone and its roof by the transverse carpal ligament. It can be divided into three portions:


Many structures pass through the carpal tunnel, such as eight flexor tendons of the fingers (four superficialis and four profundus) and the flexor pollicis longus, and usually the localization of the median nerve is superficial to the tendons and medial to the flexor pollicis longus [4] (**Figure 2**).
